Imperfect Pediatrics

I had a phenomenal day in clinic yesterday. Imperfect for sure but inspiring, connected, and busy. I felt useful and like anybody else, that feels so good to me. Productivity can be defined in various ways and yesterday I fulfilled my personal definition. I wrote an email to a friend and cardiologist this morning where I said,

But I must say, it’s a sincere fortune to be a doctor some days. Yesterday was one of those…

It was typical day in the sense that my schedule was crammed full of well child check-ups, newborn visits, and a few scattered visits for acute care–colds, depression, and belly pain. As is typical, I arrived in the morning with absolutely no open spots on my schedule. I saw 25 patients, squeezed in 2 patients to “double book” who needed to be seen by a pediatrician more urgently, and we provided vaccination updates for over 1/2 the patients. The “productive” feeling washed over me a number of times. At one point a mom said, “I knew that but I just needed you to guide me to know that I was right.” Another moment when I confirmed the correct diagnosis for a patient who’d been into doctor’s offices twice where the diagnosis had been missed. It’s exhilarating to help people understand health, highlight their understanding of science, and calm them down. Parenthood can be extraordinary (understatement of the century). The best part of my job is when I can help clear off the windshield of doubt. I do want parents to see the road…

But the day wasn’t perfect.

I ran behind at a few points due to complexities in care and conversations that extended past the allotted time.

The computer had to be restarted in exam room #4 three times, once because I hit the wrong button at login, another 2 times for reasons beyond me.

For another patient, the handout I’d printed out at the end of the visit was for a 2 month-old while the baby was 4 months-old. Wanting the family to have the correct information and links, the entire note needed to be regenerated in the EMR. Another few minutes delay and likely a sense of patient distrust.

I’m also certain that I didn’t answer every single question from every single parent. I would suggest it’s impossible to do so when you see over 20 patients in a day, all the while answering phone calls, speaking and coordinating care for patients not in the office with outside specialists, filling out school forms for taking Benadryl or playing sports, and assisting the medical team to triage and communicate with families.

Meanwhile, my email inboxes piled up. Twitter (of course) sat silent, the blog was ignored, and my stomach growled. Regardless, it was a day in pediatrics that filled me up (I felt helpful).

Today, I’m reminded how much better this can be. In my heart, I want to be available to my patients all of the time, but for reasons of practicality and self-preservation, I’m not. Social media helps by allowing me to share and listen out of the exam room, but it isn’t a cure-all for obvious reasons. Social media just isn’t set up for personalized health care–that precious partnership with a clinician we all want. I believe a more perfect practice is coming.

Perfect Pediatrics Looks Something Like This:

Availability: I have open appointments in my schedule every single day for acute medical issues for patients that consider me their pediatrician. I imagine perfect availability boosted by easy access to scheduling (no sitting on hold for 20 minutes). I see it like this: a parent can wake up, realize that they need their child to be seen, go online to book an appointment or chat with a nurse, and come in to see me (or my nurse partner) the same/next day.

Online Advice & Content: I have an up-to-date online repository of health information for families to browse and review pediatric health information when necessary. This would include videos and written content on every single vaccine we give, developmental milestones for every wellness check we do, information on every medication I prescribe, links to AAP, CDC, or leading health institutions’ health guidelines, and parenting content that helps families navigate the web intelligently. There would be directions to credible websites on buying car seats or finding coupons to do so, buying diaper cream, using and dosing anti-fever medications, and stories from wise families detailing how they made decisions raising their children. We’d highlight disease-specific groups where families can connect with other families challenged by similar circumstances or similar medical conditions. And there would be stories from my practice panel that could be shared: we all want parent “pearls”–clips from families looking back at the things they would do if they did it all again–so those would be there, too. Instead of sharing this content over and over and over again each day, it would be produced over a series of months to fill the need for families and avoid redundancy for clinicians.

Team: My patients would be cared for by a team committed to them. Nurses, schedulers, lab technicians, and medical assistants who know them, care for them at each visit, and coordinate their care between visits or with specialists. Many visits for preventative pediatrics can be completed by someone other than me, and my patients would have access to the same set of of team when they needed a nurse visit, a school form completed, a growth check, or a reminder to return for a booster shot. The team would all have access to the family’s email or cell phone so they could reach families in opted to be contacted. This team would galvanize sincere partnerships between health care and family.

E-Visits, Video-visits & Two-Way Communication: A practice where all of my patients have access to me at reasonable intervals of time from the comfort of their home. I imagine functionality where families can stream 1-minute question videos asking for guidance or diagnoses, and where I can respond with 1-2 minute video answers. Further, I imagine a practice where follow-up care is completed online or by phone or Skype-type encounters. Where teens can follow-up on their depression from their smart phone and where they can get their HIV results by text. I imagine visits where we value each others’ time and geography appropriately.

Payment: A perfect practice has payers and insurers valuing what is most precious in a medical home–expertise, personal care, time, and follow-up. Perfect includes support for content online–where advice for prevention is paid for upon completion or in global billing charges, where a visit that takes 15 minutes by phone is reimbursed at the same rate as one that takes 15 minutes in the office. More generically, a payment structure where as a physician I’m incentivized to provide professional, efficient care at the highest quality. And where I’m not incentivized to bring patients into the clinic when unnecessary. Where I am incentivized to reach my patients in ways they prefer. Even more perfect, a system that values the time it takes to communicate and utilizes the technologies of our time to make it happen rapidly.

I’ll work to make this happen. You tell me what problems you see as a parent, patient, or clinician with my schema. Imperfect on course toward perfect. Watch and see…

We feel so fortunate that we were one of those patients who was able to be worked into your schedule yesterday. We saw the orthopedic doc this morning and Isaac is now sporting a royal blue cast. He is in good spirits and will begin to heal and I have piece of mind because we have such a phenomenal pediatrician!

I love your vision, Dr. Swanson. The greatest part? All these things you dream about are really possible with the technology available at our fingertips. In addition to your points, I would add the patient experience while in the office is due for an update. Streamlining check-in, optimizing waiting room space, providing personalized health care information to review while waiting to help prepare for the visit, customized information available in the office rooms to confirm/review treatment plans, office communication of real-time wait times… and current magazines. All of these things are possible. We just need a revolution. 🙂

Great Post Wendy … I echo Natasha’s comments and also applaud and share your vision — and passion. There are those who believe that tech will drive a wedge between a provider and a patient… I do not subscribe to this theory. Quite the opposite. Technology will enable us to empower our patients, “clear their windshield of doubt” and have access to meaningful, actionable information whenever necessary. Platforms in existence, or soon to launch will enable us to initiate a dialogue before, instead of or after an in-real-life encounter. If the information available online is not enough, and an email or short video communication will not suffice, then an appointment can be scheduled online, etc…

Natahsa… I believe the “revolution” has started 🙂 I am privileged and lucky to be able to call some of the revolutionaries such as yourselves my friends and colleagues. Let’s show them how it’s done…

Yes, I totally agree. The technology really is here.
We do have live wait times in our clinic (although they are imperfect, they are a start)
We have worked on our waiting rooms–but in our clinic, specifically, we see patients of all ages and it’s difficult to make it ideal for all. Would be nice to have educational content there, roaming tablets, etc.

We’ll get there. But the concepts that are out there in medicine are alot like concept cars. You see them in the movies, not in real life…

In the perfect pediatric practice part, I would also add malpractice reform. I think most doctors treat defensively as a result of the constant looming threat of being sued. Unti then, pediatricians will order that extra lab, referral or Rx, not because the patient may need it, but because not ordering could be questioned in a court of law.

Wow. I think it is all possible except for payment reform which impededs progress in all other areas. The best way to control what we do might be to not contract with any insurance companies. A primary care revolution where all outpatient docs post their fees and people choose. But what about the cost of vaccines and medicines? I hate that I can never tell patients what their albutreol mdi, neb. Machine, spacer, inhaled steroid would cost because I don’t even know.

As a college health center with a team of professionals working with thousands of students every day, we are very much a modified pediatric practice with older adolescents and young adults with parents often still very involved in their children’s medical care.

We almost have some of your perfect practice ideals in place. We are pre-paid through a mandated fee so there are unlimited free visits and discounted, very affordable fees for procedures, labs and medications. We operate on a same day open scheduling system and will always see those who want to be seen that day. We have electronic records with customizable digital patient education that is made available via secure patient portal immediately after the visit, including a copy of the chart note, xray reports and lab values with interpretation. At least 1/2 of our daily patient encounters are now virtual–we don’t have Skype organized for routine care but it works well for our students overseas who need our consultation.

The future is here and now and is working very well at Western Washington University. And it is really fun to practice medicine using all levels of care and technology available to us.

The payment model you envision has already been developed. The model forbids insurance companies from “abusing” and controlling medical professionals and is completely legal under U.S. federal healthcare law. This is physician designed and it specifically will: give physicians 100% reimbursement, pay physicians on a per member/per month basis, and pay physicians for answering e-mails and talking to patients over the phone.

Great post. I would love to amplify two of your points, specifically payment reform and scheduling.

I hope that the move towards accountable care organizations helps things move in the direction of payment reforms as the incentives provided in the current system are perverse. It is easier (and more lucrative) to perform a test than spend extra time with patients. Moreover, I totally agree that phone or electronic follow up should be reimbursable; maybe not as much as an office visit because you cannot examine the child, but currently they are not paid for at all.

“Smart scheduling” would be really helpful to me. I see kids for sleep and breathing problems. As a rule, the sleep (and neuromuscular) patients have separate clinics because they need more time. However, even for general pulmonary clinic, a 30 minute new patient slot could be dedicated to a 5 year old with chronic cough (usually straightforward), or a child who has had a solid organ transplant with worsening cough and shortness of breath. Obviously, these two encounters will take different amounts of time and I try to address this on follow up, but I often have little info when people walk through the door. Scheduling which appropriately allocated my time based on patient complexity and my practice patterns could really improve efficiency and minimize wait times for patients

Thanks for another thought and discussion provoking post! It is so exciting to follow such ongoing innovations in medicine, and I am excited to hear more about what Emily and Matthew mentioned. I agree with Craig that issues of scheduling can make or break a ‘day in the life.’ Part of that can be addressed in the true medical home setting, as described by Wendy in the ‘dream’ team section. The more familiar the team is with the patients and families, the more they should be able to tailor the scheduled time. Even if the patient is not well known, good connectivity, including pre-filled forms, etc, can help direct time slot choices. Another component of course is the software for scheduling. Mostly they seem to be set up on inflexible templates, but the more we demand flexible systems, the more we should see 🙂

I was present at your talk in October at the Cerner Health Conference. Great talk. At the time, I had taken time away from being a clinical hospital pharmacist who did rounds, created procedures, attended committees to improve care. I was all about moving our hospital to computerized-provider order entry. I have since returned to hospital practice 4 hours out of the week. The other 4 hours are a new experience… I run a warfarin clinic for 400 patients. I find I have 6-12 minutes per patient to review their lab results over the phone and make dose changes. Your post is a good summary of what I am learning. It is both rewarding and nearly impossible to provide the best of care… and yet, every Coumadin Clinic that is managed over the phone is not reimbursed. So that is another new lesson for me… I provide care as best as possible, but it isn’t reimbursed. Even if we had face-to-face visits, pharmacists are not reimbursed anymore than $20 rather than the five levels that other health professionals are provided.

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Seattle Children’s provides healthcare for the special needs of children regardless of race, color, creed, national origin, religion, sex (gender), sexual orientation or disability. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho.